AMDIS 2014: MU and the transition of care challenge

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OJAI, CALIF.--No Meaningful Use (MU) objective is more challenging than transitions of care, according to Harris Stutman, MD, executive director of clinical informatics at MemorialCare Health System in Orange County, Calif.

In fact, it’s the area in which MemorialCare has focused most of its efforts when it comes to MU, Stutman told a group of CMIOs last week during a session on MU at the AMDIS Physician-Computer Connection Symposium.

Stutman reminded the CMIOs in the audience that when MU Stage 2 was released it was intended to focus on the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible. “This is a goal we can all endorse, and the transition of care objective is something that I think makes a lot of sense and has a strong business case behind it,” Stutman said.

But, “I think we can quibble . . . with the way it’s been defined—the objective and the way in which the measurement has been defined—within the Meaningful Use regulation,” he added. “Because I think it has required us to do a lot of things that have taken resources away from things we really wanted to do and instead had to put that into meeting the transition of care requirement as it is defined in the final Stage 2 rule.”

The complexity of the transitions of care objective is demonstrated, Stutman said, by the workbook his organization has put together containing the definitions of all the MU objectives. “Most of them average two pages, some of them three, and the really complicated ones four,” he pointed out. “The transition of care one is 15 pages.”

Stutman said that the way the transition of care measure is defined his organization can only count transitions of care to external providers—those who don’t have “native” access to its EHR.

“Now we have to talk to people we previously haven’t had a lot to do with, at least electronically,” he said. “If we are going to make Meaningful Use Stage 2 work for us we have to talk to all of these folks and that’s a major effort. Finding all the people to whom we refer patients and excluding the ones who have native access to our EHR.” 

According to Stutman, in the transition of care pre-implementation stage MemorialCare had to identify all of those external resources, and all of the ways it has been referring patients at hospital discharge or when patients are leaving emergency departments, or being referred by its 500 or so ambulatory providers. “We’ve had to market the value of all of this to the sources  . . . We’ve had to add their information to our provider directories so we can send those documents electronically, and for those who are electronically challenged and don’t have an EHR or have an uncertified EHR, we’ve actually implemented a direct messaging portal so that we can post the documents to those portals…”

In the implementation stage, Stutman explained, MemorialCare has had to develop new clinician workflows, particularly on the ambulatory side, but on the inpatient side as well. And health information management personnel, Stutman said, have had to work on both the “inbound and outside side,” dealing with issues like what happens when an electronic communication fails.

Then, when it comes to infrastructure, there are challenges involved in assembling documents, identifying the routing schema so that the information is routed appropriately, transmitting this through a health information service provider, deciding on the workflows for the error pool when the messages fail, and all the work on the code sets so that when recipients get these documents electronically they can reconcile them with their own EHRs.

All of this represents a whole number of different components that required MemorialCare work to with a variety of new vendors on things like creating the direct message portal or signing new contracts with existing vendors. “There’s lot of money there,” Stutman said. “We were probably spending a half a million dollars just on those augmented modules and capabilities to meet this requirement, without considering all of the work we’ve had to do with multiple teams—an inpatient team, an ED team, an infrastructure team, an ambulatory team and an integration team that are all working on this one measure.”

“I think there is an enormously strong business case to be made here for doing all this work,” Stutman said, particularly when external providers promptly get this information as the patient is walking out the hospital door so when a patient calls the next day, the provider already has a core set of information. “We strongly believe that means they are going to be thinking good things about MemorialCare and will be more likely to send patients to us.”

What is Stutman worried about going into 2014 and 2015? “Will we find enough non-partners in order to successfully address this measure?” he asks, pointing out that since MemorialCare has about 6,000 hospital discharges a month across the enterprise, if they lose 90 percent of them “because they are within our family, we’ll only have 500, and we’ve got to find among those 500 enough folks to work with us in this transmission process.”

Stutman concluded by noting that devoting his individual time to issues involving transition of care, “not to mention the 30 or 40 people working on this, is a key challenge, and identifying sufficient resources and allocating sufficient dollars, given the numbers, is a real challenge in 2014 . . . and will continue.”